Exam 2-Peds
Which parental statement indicates correct understanding for the prevention of sunburn for a toddler-age client? "I will use a sunscreen with an SPF of 30 or higher for my child." "I will keep my child indoors when the sun is out." "I do not have to reapply sunscreen unless they are playing in water." "I will make sure my child wears long sleeves and long pants while outside."
"I will use a sunscreen with an SPF of 30 or higher for my child." In order to protect the toddler-age client from sunburn it is important to keep him or her out of the sun between 10 AM and 2 PM, ensure the child wears a baseball cap while outside, reapply sunscreen with profuse sweating, and make sure the child is dressed in cotton clothing with a tight weave. These statements all indicate correct understanding of the information presented by the nurse. An SPF of 30, not 15, or higher should be applied to prevent sunburn
A 1-year-old child has a congenital cardiac malformation that causes right-to-left shunting of blood through the heart. What clinical finding should the nurse expect? A. Increased hematocrit B. Proteinuria C. Peripheral edema D. Absence of pedal pulses
Polycythemia, reflected in an increased hematocrit reading, is a direct attempt by the body to compensate for the decrease in oxygen to all body cells caused by the mixture of oxygenated and deoxygenated circulating blood. Proteinuria is not a characteristic of heart malformations that cause right-to-left shunting of blood; nor is edema. An absence of pedal pulses is characteristic of coarctation of the aorta, an obstructive malformation.
A 4-month-old infant is admitted to the pediatric unit with a diagnosis of congestive heart failure. Which nursing assessment would most accurately demonstrate improvement in the infant's condition? A. Weight loss during next 2 days B. Decreased tremors C. Increased hours of sleep D. More rapid heart rate within 2 days
Weight loss indicates fluid loss. Water retention is a classic sign of congestive heart failureLinks to an external site.. Tremors are not typical in infants with heart disease. Tremors are related to central nervous system irritability. If the infant's condition improved, energy would increase and sleeping needs would decrease. Tachycardia is a sign of congestive heart failure. The purpose of the cardiotonic is to slow the heart rate.
What findings should a nurse expect when examining the laboratory report of a preschooler with rheumatic fever? A. Positive antistreptolysin titer B. Negative C-reactive protein C. Increased reticulocyte count D. Decreased sedimentation rate
A positive antistreptolysin titer is present with rheumatic fever because of the previous infection with streptococci. An increased reticulocyte count is usually related to a decrease in mature red blood cells caused by hemorrhage or blood dyscrasias; it is unrelated to an infectious or inflammatory process. A positive, not a negative, C-reactive protein will be present; this is indicative of an inflammatory process. The erythrocyte sedimentation rate will be increased, not decreased, indicating the presence of an inflammatory process.
A 4-year-old child is undergoing a diagnostic workup for pulmonic stenosis. The mother asks the nurse about the diagnosis. How does the nurse describe pulmonic stenosis? A. Narrowing of the valve between the right ventricle and the pulmonary artery B. Narrowing of the valve between the left atrium and left ventricle C. Hardening of the valve between the right atrium and right ventricle D. Hardening of the valve between the right ventricle and the arch of the aorta
The pulmonic valve is located between the right ventricle and pulmonary artery. The cusps of the valves may be fused, or the infundibulum below may be hypertrophied, thereby restricting blood flow to the lungs. The mitral, tricuspid, and aortic valves are not involved in pulmonic stenosis
A nurse in the pediatric clinic is teaching a mother how to care for her infant who has eczema. What is most important for the nurse to teach the mother? Preventing secondary infections Ensuring physical growth Identifying causative factors Providing adequate hydration
Preventing secondary infections The skin integrity of children with eczema is compromised by constant scratching; affected children are prone to streptococcal and staphylococcal infections. Although ensuring growth is important, it is not the priority. An exact cause may never be identified. Although providing adequate hydration is important, it is not the priority.
An infant with a congenital heart defect is returned to the unit after cardiac catheterization. The nurse manager is observing a nurse newly assigned to the unit. Which nursing intervention should the nurse manager interrupt? A. Performing range-of-motion exercises B. Offering fluids and foods as tolerated C. Monitoring the apical pulse for rate and rhythm D. Assessing the pulses distal to the catheterization site
Range-of-motion exercises of the limb bearing the catheterization site might cause the dislodgement of a clot and result in hemorrhage. Intake should start with fluids and progress as tolerated. The apical pulse is monitored because a common complication after cardiac catheterization involves disturbances of cardiac rate and rhythm. The peripheral pulses are assessed because formation of thrombi is a complication of cardiac catheterization.
A child with a diagnosis of tetralogy of Fallot exhibits an increased depth and rate of respirations. On further assessment, the nurse notes increased hypoxemia. The nurse interprets these findings as indicating which situation? A. A hypercyanotic episode B. Anxiety C. Temper tantrum D. The need for immediate health care provider information
Rationale: Children with tetralogy of Fallot or similar physiology may experience hypercyanotic episodes, or tet spells. These episodes are characterized by increased respiratory rate and depth and increased hypoxia. Immediate health care provider (HCP) notification is not required unless other appropriate nursing interventions are unsuccessful. Anxiety and a temper tantrum are unrelated to tetralogy of Fallot.
A 5-year-old-child is undergoing chemotherapy. The mother tells the nurse that the child is not up to date on the required immunizations for school. What is the best response by the nurse? "This isn't the best time to finish the immunizations, because your child's immune system is suppressed." "Maintaining current immunizations is critical. Make sure the series is completed." "By this time your child has developed sufficient antibodies to provide immunity." "It's important to complete the immunizations because your child needs to be protected from childhood diseases that could be fatal."
"This isn't the best time to finish the immunizations, because your child's immune system is suppressed." Chemotherapy compromises the immune system. The vaccines may be administered after the completion of the chemotherapy protocol, once the immune system has returned to its previous state. The child has not developed sufficient antibodies; booster immunizations are needed, but not at this time. Administering immunizations at this time could prove fatal.
To evaluate kidney function, the nurse must accurately measure the hourly urine output of a 1½-year-old toddler weighing 22 lb (11 kg) who has been admitted with extensive burns. What is the minimum safe output per hour for a child this age? 10 to 20 mL 61 to 80 mL 41 to 60 mL 21 to 40 mL
10 to 20 mL The minimum safe urine output for a 1½-year-old toddler is 1 mL/kg/hr. The 18-month-old toddler whose weight is at the 50th percentile weighs 11 kg. This is 11 mL/hr, which is within the minimum safe output of 10 to 20 mL/hr. Urine output range of 61 to 80 mL/hr and 41 to 60 mL are more than the minimum output for any age group. A urine output range of 21 to 40 mL/hr is the minimum safe output for children who weigh 21 to 40 kg and are 5 to 11 years old.
A 5-year-old child undergoes cardiac catheterization. The child is in the post-cardiac catheterization unit for 2 hours when the incoming nurse receives the report from the outgoing nurse. Which part of the child's report should the incoming nurse question? A. Bed rest with bathroom privileges B. Vital signs every 30 minutes C. Voided 100 mL since admission D. Pressure dressing over entry site
Children are kept on complete bed rest for 4 to 6 hours after cardiac catheterizationLinks to an external site. to reduce the risk of bleeding or trauma at the insertion site; the report regarding bathroom privileges should be questioned. Frequent assessment of vital signs is part of routine postcatheterization care. Urine output of 100 mL is within acceptable limits for a child of this age; oral fluids are encouraged to promote hydration and urination. A pressure dressing is placed over the insertion site to prevent bleeding. This is routine postcatheterization care.
The parent of a 5-month-old infant with heart failure questions the necessity of weighing the baby every morning. What does the nurse say that this daily information is important in determining? A.Fluid retention B. Kidney function C. Nutritional status D. Medication dosage
Fluid retention is reflected by an excessive weight gain in a short periodLinks to an external site.. Inadequate cardiac output decreases blood flow to the kidneys and thus leads to increased intracellular fluid and hypervolemia. Although this assessment may add information to the data regarding kidney function, other assessments, such as hourly urine output, blood urea nitrogen concentration, and creatinine level more significantly reflect kidney function. Weight gain resulting from nutritional intake is gradual and will not vary greatly on a day-to-day basis. Although weight is used to determine medication dosages, dosages do not need to be recalculated according to changes in daily weights.
A 3-year-old child is scheduled for cardiac catheterization. What is the priority nursing care after this procedure? A. Monitoring the site for bleeding B. Encouraging early ambulation C. Restricting fluids until the blood pressure has stabilized D. Comparing blood pressure readings in the lower extremities
Hemorrhage is a major life-threatening complication because arterial blood is under pressure and a catheter has been inserted into an artery. The child is kept in bed for up to 6 hours after an arterial catheterization. Fluids may be given as soon as they are tolerated. Pulses, not blood pressure, must be compared for quality and symmetry.
A parent of a 7-year-old child asks a nurse how to tell the difference between measles (rubeola) and German measles (rubella). What should the nurse tell the parent differentiates rubeola from rubella? High fever and Koplik spots Rash on the trunk and pruritus Nausea, vomiting, and abdominal cramps Characteristics of a cold, followed by a rash
High fever and Koplik spots The signs and symptoms of rubeola (measles)Links to an external site. include a high fever, photophobia, Koplik spots (white patches on the mucous membranes of the oral cavity), and a rash. Rubella (German measles) usually does not cause a high fever, runs a 3- to 6-day course, and never causes Koplik spots. The rash of rubeola (measles) spreads over most of the body. Nausea, vomiting, and abdominal cramps are vague clinical findings and occur with many illnesses. Some signs and symptoms may be similar to those of a severe cold, but rubeola is associated with high fever.
A 12-month-old infant has become immunosuppressed during a course of chemotherapy. What information regarding the measles, mumps, and rubella (MMR) vaccine should the nurse, preparing for the infant's discharge, give the parents? Infants who are receiving chemotherapy should not be given these vaccines. It should not be given until the infant reaches 2 years of age. It should be given to protect the infant from contracting any of these diseases. The parents should discuss this with their healthcare provider at the next visit.
Infants who are receiving chemotherapy should not be given these vaccines. The MMR vaccine is composed of live attenuated virus, and its administration could be life threatening for an immunosuppressed child. When the infant reaches 12 to 15 months of age and if the blood values have returned to normal, the MMR vaccine should be given. Because the MMR vaccine is composed of live viruses, giving it while the infant is immunosuppressed can be as life threatening as the disease itself. It is the nurse's responsibility to provide this information at the time of discharge.
A 4-year-old child is being transported to a trauma center for treatment of a partial- and full-thickness burn injury that is estimated as covering more than 40% of the body. The nurse anticipates that which treatment will be prescribed initially? Insertion of a Foley catheter Insertion of a nasogastric tube Administration of an anesthetic agent for sedation Application of an antimicrobial agent to the burns
Insertion of a Foley catheter A Foley catheter is inserted into the child's bladder so that urine output can be accurately measured on an hourly basis. A nasogastric tube may or may not be required but would not be the priority intervention. Although pain medication may be required, the child would not receive an anesthetic agent and should not be sedated. The burn wounds would be cleansed after assessment, and an antimicrobial agent may be prescribed. Intravenous fluids are administered at a rate sufficient to keep the child's urine output at 1 ml/kg of body weight per hour, thus reflecting adequate tissue perfusion.
A nurse explains to the mother of a 1-year-old with a history of frequent ear infections that the primary cause of otitis media in young children is what? A. Obstructed eustachian tube B. Sinusitis C. Recurrent Tonsillitis D. An inflamed mastoid process
Obstructed eustachian tube A blocked eustachian tube impairs drainage and creates negative pressure; when the tube opens, bacteria are pulled into the middle ear. Sinusitis is not related to otitis media. Recurrent tonsillitis is not the direct cause of otitis media. Mastoiditis is a complication, not a cause, of otitis media.
A school-aged child is brought to the emergency department with partial- and full-thickness burns of the lower extremities. The practitioner writes multiple prescriptions. What is the nurse's priority intervention? Starting an intravenous line with a large-bore catheter Administering oxygen Inserting a urinary catheter Giving prescribed pain medication
Starting an intravenous line with a large-bore catheter Because of the location and degree of burns, an IV line for fluid restoration and access for pain medications is the priority. Oxygen is not needed because the airway is not involved and oxygen deprivation has not been identified. The insertion of a urinary catheter is a secondary action after fluid administration begins. Although giving pain medication is important, an IV infusion for fluid restoration to prevent hypovolemic shock is the priority. Pain medication for both children and adults with burns usually is administered through an IV catheter.
The parent of a 10-month-old infant with otitis media tells the nurse in the pediatric clinic that this is the baby's third episode in 3 months. The infant is tugging at the ear but is not acutely ill. What factor should the nurse consider before responding? A. The eustachian tube is short and horizontal. B. Analgesics are contraindicated. C. Oral antibiotics will be prescribed. D. The labyrinth and cochlea are inflamed.
The eustachian tube is short and horizontal. This anatomical difference in young children permits easier migration of microorganisms from the oral cavity into the middle ear, predisposing them to otitis mediaLinks to an external site.. Analgesics such as acetaminophen or ibuprofen are recommended to relieve discomfort. Studies have shown that antibiotics are not effective in children younger than 2 years if the child is not severely ill. Antibiotic therapy is necessary when the infant has a fever or is in severe pain. The labyrinth and cochlea are part of the inner ear and are not affected by otitis media.
The nurse is planning care for a preschooler with Kawasaki disease. Which intervention should the nurse plan to implement? A. Administering intravenous immune globulin (IVIG) as prescribed B. Restricting fluids, especially fruit juices C. Ensuring bright lighting in the room during assessments D. Administering penicillin G benzathine (Bicillin) as prescribed
treated with high-dose IVIG in combination with aspirin to lower the risk of coronary artery abnormalities. Nursing care is focused on adequate hydration, so fluids should not be restricted and fruit juices are not contraindicated. A clinical manifestation of bilateral nonpurulent conjunctivitis occurs with Kawasaki disease, so the nurse should avoid bright overhead lights. Kawasaki disease is an acute febrile exanthematous illness of children with a generalized vasculitis of unknown origin. It is not an infectious disease, so antibiotics (penicillin) are not administered.
